INITIAL COMMENTS
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This report is a result of a supervisory review of the written report of the findings of an on-site licensure inspection that was conducted on January 21-28, 2014 by staff from the Division of Drug and Alcohol Program Licensure. Based on the supervisory review of findings from the on-site inspection, Pennsylvania Counseling Services, was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this supervisory review:
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Plan of Correction
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704.6(a) LICENSURE Clinical Supervisor Qualifications
704.6. Qualifications for the position of clinical supervisor.
(a) A drug and alcohol treatment project shall have a full-time clinical supervisor for every eight full-time counselors or counselor assistants, or both.
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Observations
Based on a supervisory review of the "Staffing Requirements Facility Summary Reports" for all of the facilities in the Project, the Project failed to ensure that there was one full-time clinical supervisor for every eight full-time equivalent (FTE) counselors in the Project.
The findings include:
The "Staffing Requirements Facility Summary Reports" for the nine facilities that make up the project list a total of 24.08 FTE's who are fee-for-service employees and/or full- or part-time employees.
The "Staffing Requirements Facility Summary Reports" for each of the nine facilities within the project revealed that only one of the employees listed as a clinical supervisor was full time. A full-time equivalency of 24.08 counselors and/or counselor assistants requires a minimum of 3 full-time clinical supervisors within the project.
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Plan of Correction
The Project Director will oversee that PCS maintains a full-time clinical supervisor for every eight FTE counselors in the project. Two of our clinical supervisors have increased their hours to full-time so that PCS is currently in compliance with this regulation.
The Vice President of Quality Improvement or designee will monitor the FTE total for the project's counselors to ensure that PCS maintains adequate clinical supervisory coverage.
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704.11(c)(1) LICENSURE Mandatory Communicable Disease Training
704.11. Staff development program.
(c) General training requirements.
(1) Staff persons and volunteers shall receive a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum. Counselors and counselor assistants shall complete the training within the first year of employment. All other staff shall complete the training within the first 2 years of employment.
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Observations
Based on a review of the facility's staffing requirements facility summary report (SRFSR), the facility failed to ensure that staff persons and/or volunteers received a minimum of 6 hours of HIV/AIDS and at least 4 hours of tuberculosis, sexually transmitted diseases and other health related topics training using a Department approved curriculum as per the regulatory requirements in one of eleven records reviewed.
The findings include:
The facility's SRFSR form completed by the facility on January 22, 2014 was reviewed on March 27, 2014. The form listed one staff as not having completed the mandatory training within the regulatory time frames
Employee #7, a support staff person, was hired on October 11, 2010. Employee #7 was required to obtain 6 hours of HIV/AIDS training and 4 hours of TB/STD training by October 11, 2012. The training was not documented as of the date of the inspection.
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Plan of Correction
Employee #7 resigned from Renaissance Crossroads of Pennsylvania Counseling Services effective 1/9/14. The Director of Quality Improvement has created a tracking system to ensure that all clinical staff and support staff receive necessary trainings within the required timeframes. The Director of Quality Improvement sends monthly reminders and will contact staff to ensure that trainings are obtained within the required timeframe. |